On the surface, the study by Thorpe and colleagues (1) seems to be only about medication prescribing for dementia in the Veterans Affairs (VA) system, but it could serve as the basis for an entire medical school course on health policy. It has far-reaching implications for health care system design, medication prescribing, and daily clinical practice, particularly for the care of patients with chronic disease. The study highlights an overarching concept: “Every system is perfectly designed to achieve the outcomes it gets.”

Health policy decisions in the United States give priority to consumer choice, especially as it relates to expanded access to care (2). The assumption is that more convenient access coupled with choice will be best for patients. But Thorpe and colleagues show that expanding access and choice can have a significant downside, particularly when the health care system increases choice without also focusing on care coordination and information exchange between providers. The researchers followed veterans with dementia who received their medications only within the VA system (VA-only users) and those who also received medications outside the VA system through Medicare Part D (dual users) (1). They found that dual users had more than double the odds of exposure to medications that increase a person's risk for adverse events. On average, dual users received these potentially harmful medications for 1.5 months longer than VA-only users.